Initial Qestioannaire-Canine Dermatology

IMPORTANT NOTES

Itchiness in pets includes the following: Itching, Scratching, Licking, Chewing, Biting, Rubbing, Scooting (rubbing of hind end), and Head Shaking.
Ears and paws are common areas affected by allergies. Some dogs may experience ear infections or frequently lick and bite their paws before developing skin issues elsewhere. When discussing your dog’s “skin,” please consider the paws and ears as part of the overall condition.
This questionnaire is designed to help both you and our veterinary staff prepare for your appointment. Please fill out this form and return it to Us at least one day before your scheduled visit.
If you don’t know the answer to a question or don’t understand the question please leave the answer blank. DO NOT guess.

Owner Name

Phone Number

Pet Name

Sex

Ages

Your pets is neutered/spayed

Yes No

Have you recently moved with your pet? (Yes/No/International)

If YES, please provide details including the timing of the move:

Has your pet had any allergy testing done previously?

Yes No

If YES, where and when?

Have you noted a loss in your pet’s weight?

Yes No

Have you noted weight gain in your pet?

Yes No

Have there been any changes in your pet’s activity levels?

Yes No

Have you noticed any changes in your pet’s thirst or urination habits?

Yes No

Have there been any changes in your pet’s energy levels?

Yes No

Have you noticed any changes in your pet’s thirst or urination habits?

Yes No

Has your pet received treatments for intestinal problems/upset in the past?

Yes No

How many bowel movements does your pet have per day?

Does your pet have any non-dermatology related health conditions or illnesses? If so please provide details:

Approximate date or age of when your pet’s symptoms FIRST started

If problem has been continuous for over a year, did it start off as seasonal?

Yes No

How itchy is your dog currently on a scale of 1 to 10? (Please use the Canine and Cat Pruritus Analog Scale to help in assessment of your pets itch score),

Are symptoms getting worse?

Yes No

Is there a time when your pet is more or less itchy?

Yes No

If yes, please provide more details on variations in itch:

Was the “itchiness” the first symptom you noticed?

Yes No

Do you feel like your cat over-grooms him/her self ?

Yes No

How much time does your pet spend: (Indoors %/ Outdoors %)

Type of flooring in your residence: (Carpeted Flooring %/ Tile-wood-cement %)

Oral Medications (Pills, Capsules, Liquids, Tablets)?

Topical Medications (Medicated Shampoos, Creams, Ointments, Lotions, Sprays)?

Ear (Aural) Medications (Drops, Flushes, Ointments)?

Ophthalmic (Eye) Medications?

Did your pet have a negative/adverse reaction to any of the above medications? If yes, please list:?

Initial Qestioannaire-Canine Dermatology

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